Massey t lnivarsity Lib, ary
EXPECTATIONS AND ANXIETY ABOUT
COUNSELLING
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15
FOR
EXPECTATIONS AND ANXIETY ABOUT
COUNSELLING
A thesis presented in partial fulfilment
of
the requirements for the degree
of
Master of Arts
in
Psychology at
Masse
y
University
HA1\1ISH JOHN MCLEOD
11
ABSTRACT
Prior research into expectations about counselling has assumed that failing to meet client
expectations will have a detrimental effect on process variables such as state anxiety and
adherence to treatment. However, the empirical support for this is equivocal. Both
self-regulation theory and the attentional-bias model suggest that experiencing the confumation of accurate, but negative expectations will result in an increase in state anxiety. Therefore,
instead of focussing only on improving accuracy of client expectations it is suggested that
the affective valence of the expectations must also be acknowledged. The aim of the
present study was to investigate the differential effects of confirmation/disconfirn1ation of
positive or negative expectations on anxiety about seeing a counsellor. Thirty-nine adult
clients attending their first session at a university counselling centre completed pre-and
post-session measures which assessed their expectations about counselling, and state and
trait anxiety. As hypothesised, the effects of disconfirrnation of expectations on state
anxiety were moderated by the valence of the expectations. However, contrary to what was predicted, those client's who experienced confirmation of negative expectations did
not display greater state anxiety than those with positive expectations, and there was no
significant relationship between trait anxiety and negative expectations. Simple exposure
to therapy resulted in a decrease in state anxiety for all clients regardless of
confumation/disconfirmation and expectation valence. Finally, those clients who had their negative expectations confirrned did not drop out of treatment more than any other group.
A preliminary investigation of the validity of using the Expectations About Counseling
questionnaire (EAC) to measure positive and negative expectations about counselling
revealed that it was not as effective as had been suggested by previous researchers. It was
concluded that this factor and a lack of power contributed to the paucity of significant
results. The results are discussed in the context of self-regulation theory and the attentional-bias model and an argument is made for the continued use of these two
111
ACKNOWLEDGEMENTS
I would like to express my gratitude to all those people who have supported me during the
completion of this project. Firstly, I extend my thanks to Dr. Arnold Chamove for
accepting the task of guiding me through my first attempt at psychological research.
Secondly, I would like to thank all of the members of the "Psychology Cottage
Community" who provided support, friendship and consultation when it was needed. I am
in no doubt that the being in that environment enhanced the speed of my write-up while the atmosphere of good humour kept me sane.
I extend my thanks to all the staff at the Massey University Counselling Service, especially Julia and Marilyn who conscientiously dealt with the administration of the questionnaires
and in doing so extended their already considerable workload. Thanks also to Dr. Bill Zika
for his encouragement at the conceptual stage of the work. In addition to this I
acknowledge those who gave their time to participate in the study.
Thankyou to all those members of the Massey University Psychology Department, both students and staff, who expressed an interest in my work and provided light relief when it was needed. Similarly, thankyou to my friends who ensured that I did not forget that life
is not all about studying.
Thanks also to my family, especially my parents who have supported and encouraged me
throughout my university career. I am grateful for your constant concern and willingness
to lend a hand in whatever way possible.
Finally, I would like to thank Dr. Frank Deane who provided the initial idea for the project
and has been involved from the beginning. Your enthusiasm and energy was the perfect
foil to my laid-back approach. My only regret is that it cost me a bottle of wine to learn that
lV
CONTENTS
Abstract ... ... 11
Acknowledgements ... ... m Table of contents ... iv
List of tables and figures ... vi
Chapter 1: The Development of Research into Expectations About Counselling ... 1
1.1 Overview of the introduction ... 1
1.2 The origins of research into client expectations about counselling ... 1
1.3 Expectations and adherence to treatment ... 2
1.4 Expectations and satisfaction ... 3
1.5 Expectations and gender ... 4
1.6 Expectations and service utilisation ... 4
1. 7 Expectations and client ethnicity ... 5
1.8 General research into client expectations ... 6
1.9 A summary of the main problems with expectations research ... 7
Chapter 2: Preparation for Stressful Medical Procedures and Self-Regulation Theory ... 9
2.1 Rationale for drawing on the medical psychology literature ... 9
2.2 An overview ofresearch into coping with stressful medical procedures ... 9
2.3 Sensory Vs. procedural preparatory information ... 10
2.4 Expectations, pre-operative emotional states and recovery ... 12
2.5 The development of theory ... 12
2.6 Self-regulation theory ... 13
2.7 Two interpretations of the self-regulation model.. ... 14
2.8 Leventhal's interpretation ... 15
2.9 Johnson's interpretation ... 16
2.10 Summary ... 17
Chapter 3: The Attentional-Bias Model ... 19
3.1 Perceived threat and emotional arousal.. ... 19
3.2 The attentional-bias model ... 19
3. 3 Schemata ... 20
3.4 "Danger schemata" ... 21
3.5 Summary of research into the allocation of attention to threat ... 21
3.6 The relative influence of trait vs. state variables in the allocation of attentional resources ... 23
3.7 Integrating the attentional-bias and self-regulation mcxiels ... 25
3.8 Summary ... 26
Chapter 4: Recapitulation and Hypotheses ... 27
4.1 Recapitulation ... 27
4.2 Clarifying terms ... 28
4.3 Hypotheses ... 29
Chapter 5: Method ... 32
5.1 Subjects ... 32
5.2 Instruments ... 32
5.3 Expectations About Counseling questionnaire (EAC) ... 33
Psychometric Properties of the EAC ... 34
The EAC as a measure of global positive or negative attitudes toward counselling ... 34
5.4 State-Trait Anxiety Inventory - Version Y (STAI-Y) ... 35
Psychometric Properties of the ST AI-Y ... 36
[image:8.570.43.502.39.782.2]5.6 Measuring adherence to treatment ... 38
5.7 Procedure ... 38
5.7 Ethical considerations ... 39
5.8 Statistical Analyses ... 40
Chapter 6: Results ... 41
6.1 An overview of the results ... 41
6.2 Hypothesis 1 ... 41
6.3 Defining positive, neutral and negative expectations ... 43
6.4 Hypothesis 2 ... 44
6.5 Re-testing hypothesis 2 ... 45
6.5 Hypothesis 3 ... 46
6.6 Hypothesis 4 ... 47
6.7 Hypothesis 5 ... 47
6.8 Supplementary Analyses ... 49
6.9 The relationship between specific subscales and state anxiety ... 51
Chapter 7: Methodological, Theoretical and Clinical Implications of the Results ... 52
7 .1 Re-emphasising the essential features of the current study ... 52
7.2 Challenging the "congruency hypothesis" ... 52
7.3 Limitations of the EAC as a measure of negative expectations ... 54
7.4 Rationale for questioning Prospero's (1987) interpretation ... 55
7.5 Alternatives to Prospero's (1987) interpretation ... 56
7.6 The EAC as a measure of "confidence" of expectations ... 58
7.7 Low-positive versus negative expectations - a semantic issue ... 58
7 .8 Theoretical implications of the results ... 59
7.9 The consequences of confirming positive versus negative expectations ... 60
7 .10 The relationship between trait anxiety and negative expectations ... 61
7.11 Negative expectations and adherence to treatment.. ... 63
7 .12 The effects of disconfirming negative expectations ... 64
7 .13 The integration of self-regulation theory and the attentional-bias model ... 66
7 .14 Clinical implications of the current research ... 67
Chapter 8: Summary and Conclusions ... 69
8.1 Summary of the present research ... 69
8.2 Specific implications of the present research ... 69
8.3 Recommendations for future research ... 69
8.4 Concluding commen~ ... 70
References ... 71
Appendices: Appendix A: Questionnaire I ... 77
Appendix B: Questionnaire 2 ... 84
Appendix C: Subscales of the EAC ... 90
Appendix D: Questionnaire 3 ... 91
Appendix E: Adherence Form ... 94
Appendix F: Subject Consent Form ... 95
Appendix G: Instructional Flowchart ... 96
Appendix H: Counsellor Consent Form ... 99
VI
LIST OF TABLES
Table 5.1: Instruments used to measure experimental constructs ... 34
Table 6.1: Multiple regression of state anxiety on positiveness and confirmation of
expectations ... 43 Table 6.2: Percentage agreement by 15 raters for positive items from the short form of the
EAC ... 45 Table 6.3: Proportion of clients who failed to attend their next scheduled appointment by
positiveness of expectations and degree of confirmation ... 48
Table 6.4: Comparison of mean state anxiety scores at pre- and post-initial counselling
session for clients with confirmed or disconfirmed positive or negative
expectations ... 49 Table 6.5: Comparison of means and standard deviations for EAC scales observed in the current study and by Hardin et al. (1988) ... 51 Table Al: Mean scale scores and standard deviations for the current study, and
comparison of internal consistency reliability coefficients (Cronbach's alpha) for
the current study and Tinsley et al.'s (1980) original sample... 101 Table A2: Percentage agreement on ratings of EAC items for positiveness, neutrality and
negativeness by independent raters ... 102 Table A3: Pearson correlation matrix of EAC scale scores for first-time counselling centre
clients ... 103 Table A4: Comparison of means and standard deviations on the ST AI trait scale for
participants in the current study (clients with positive and negative expectations) and normative data from Spielberger (1983) ... 104
LIST OF FIGURES
CHAPTER ONE
The Development of Research into Expectations About Counselling
1.1 Overview of the introduction
It has long been thought that gaining an understanding of the ways client expectations influence therapy will benefit both the practicing clinician and the recipient of any treatment. For instance, Bordin (1955) advocated the modification of counsellor behaviour in order to meet client expectations and thus reduce anxiety and treatment avoidance. However, much of the research in this area is methodologically weak and has been predicated on unsubstantiated assumptions. One such assumption is that disconfirrning client expectations inevitably has a detrimental effect on the therapeutic process (eg. Baekeland & Lundwall, 1975). For the purposes of the current research, this assumption will be referred to as the "congruency hypothesis" as it infers that achieving congruency between client expectations and experience is of prime therapeutic importance.
Despite the fact that the congruency hypothesis is not drawn from any clear theoretical base, it's widespread acceptance has led many researchers to develop induction procedures for client's entering psychotherapy. This highlights a major weakness in this area, that is, the development of theory has failed to keep up with
applied research. Consequently, the findings of research into client expectations about counselling have been equivocal.
Improving understanding of the influence of client expectations on therapy can best be achieved by: (a) acknowledging and avoiding the methodological problems identified in previous studies; and, (b) drawing theoretical input from related, but more theoretically advanced disciplines. Therefore, the current work begins with an overview of research into client expectations with particular emphasis on the problems that have compromised previous studies. Following this is an examination of developments in the area of medi~al psychology, specifically the emergence of self-regulation theory, and the influence of expectations on preoperative emotional states
and post-operative recovery. Self-regulation theory is then discussed in terms of expectations about psychological counselling.
The Development of Research into Expectations About Counselling 2
away from the threat and rep011 less state anxiety. Therefore, it seems plausible that focussing on the negative aspects of an impending experience (holding negative expectations) will increase state anxiety and may adversely influence that experience. Whether or not the expectations are accurate may well be immaterial, the important factor may be whether they are predominantly positive or negative.
The current study has three main objectives. Firstly, it aims to address the gap that exists between theory and applied research into expectations about counselling. Secondly, it will attempt to test the congruency hypothesis by examining the
relationship between positive versus negative expectations about counselling and state anxiety. Finally, the way expectations and anxiety influence premature termination of treatment will be briefly discussed in order to provide a preliminary insight into the way these variables may influence therapeutic outcome.
1.2 The orifins of research into client expectations about counsellinf
The idea that client expectations play an important role in counselling has been examined frequently over the past four decades. Numerous studies have attempted to link expectations to: adherence to treatment (Baekeland & Lundwall, 1975; Hardin, Subich, & Holvey, 1988; Hynan, 1990); satisfaction (Lebow, 1982); therapeutic outcome (Sipps & Janeczek, 1986); service utilization (Kushner & Sher, 1989; Tinsley, Brown, de St. Aubin, & Lucek, 1984); client ethnicity (Yeun & Tinsley, 1981); psychosocial development (Tinsley, Hinson, Holt, & Tinsley, 1990); and gender (Hardin & Yanico, 1983; Sipps & Janeczek, 1986). Yet, despite the presence of these and other studies Hardin & Subich (1985) state that " ... the most important questions that remain to be answered concern the practical significance of expectations
on the actual counseling process, the ways expectations affect the outcome of counseling, and how expectations are modified over the course of counseling." (p.134).
The 1950's is the point in time from which most of today's expectations research has emanated. Kelly (1955) postulated that clients' hold a personalised conceptualisation of the therapeutic relationship and the th,erapists role within that relationship, before they even enter the first session. This idea was developed further by Goldstein (1962b, cited in Duckro, Beal, & George, 1979, p.260) who delineated
The Development of Research into Expectations About Counselling 3
Through much of the 1960's, the importance of achieving client-therapist
congruency became fixed in the minds of theorists and practicing counsellors alike.
Unfortunately this uncritical acceptance of the congruency hypothesis was followed by
the emergence of applied studies which were not based on any empirically supported
theories. The consequence of this has been that the field has developed in a haphazard
and inefficient manner. The following is an overview of research into client
expectations and their relationship to specific aspects of the counselling process.
1.3 Expectations and adherence
to
treatmentBaekeland and Lundwall (1975) completed an extensive, and often cited,
review of the premature termination of treatment literature and emphatically stated that
" ... discrepant expectations about treatment promote dropping out." (p.758). However,
this conclusion was supported by the citation of only six studies, five of which were
published prior to 1965.
More recent research has been marked by ambiguous results and semantic
problems. For instance, Hardin et al. (1988) used the Expectations About Counseling
Questionnaire (EAC, Tinsley, Workman, & Kass, 1980) to link client expectancies to
premature termination of treatment The results provided no support for the hypothesis that differences in precounselling expectations can explain differences in tennination
status. Also, they found that problem type did not seem to affect expectations.
Hardin et al. (1988) make several recommendations for future research.
Firstly, they encourage the formulation of clear definitions of concepts such as premature termination, and state that client expectations must be treated as something
distinct from client preferences. They also question the ability of the EAC to measure
discrete client expectations and suggest that this possible lack of sensitivity may have
contributed to their non-significant results. In support of this Hardin et al. cite the doctoral work of Prospero (1987) which suggested that, rather than assessing discrete
expectations, the short form of the EAC may be a measure of global positive or
negative set toward counselling. This suggestion is highly pertinent to the current
study and supports the contention that too much attention has been paid to discrete
expectations and their accuracy rather than exploring the role of the predominant
affective valence of an individual's expectations.
Heesacker and Heppner (1988) postulated that client motivation and
expectations should predict premature tennination and, like Hardin et al. (1988), they
encouraged the formulation of clear construct definitions. Instead of using an arbitrary
definition of premature tennination based on the number of completed therapy sessions,
the authors made their assessment based on the careful analysis of therapist notes. The
main findings were that in brief psychotherapy, those who tenninated prematurely
The Development of Research into Expectations About Counselling 4
psychotherapy, premature terminators reported more favourable expectations. This
finding is consistent with increasing recognition that different factors may influence
dropping out in various phases of treatment (eg. Baekeland & Lundwall, 1974;
Pekarik, 1985a). Heesacker and Heppner attempted to explain this by suggesting that a
person with negative expectations may have them confirmed more rapidly due to a scanning and memory bias which favours negative material. In contrast, they suggest
that those who hold positive expectations which are disconfirmed become gradually disillusioned. This proposition is consistent with the attentional-bias model discussed
in Chapter 3, and suggests that allaying a first-time client's negative expectations may
be necessary to ensure that they adhere to treatment long enough to gain some benefit
from it.
Hynan (1990) found that early terminators discontinued therapy due to
discomfort and situational constraints more often than late terminators. Those who ended therapy later did so because of improvement attributed to the therapeutic
experience. Hynan suggested a modest relationship exists between positive
experiences in therapy and adherence but this observation failed to reach significance
(most probably due to the small sample size used). When viewed in the light of other
research (such as Heppner & Heesacker, 1988) it would seem that fostering positive expectations prior to counselling and minimising negative experiences in the initial sessions is desirable as this should increase adherence and enhance the possibility that
an individual will be exposed to therapy long enough for it to do some good.
In summary, the exact influence of expectations on adherence to treatment is still unclear. However, there is evidence which indicates that the affective valence of
expectations and the subsequent confirmation or disconfirmation of those expectations
may relate closely to termination status. It is intended that the current study will explore this issue.
1.4
EXJJectations and satisfaction
An extensive review dealing with satisfaction with mental health treatment
revealed that few conclusions can be drawn from previous research (Lebow, 1982).
This was attributed to the newness of the field complicated by problems with some of
the techniques used to assess consumer satisfaction. The role that client expectations
play in determining satisfaction was also unclear. For instance, Severinson (1966,
cited in Lebow, 1982) reported that disconfirming client expectations regarding
counsellor empathy inevitably reduced satisfaction, while Gladstein (1969, cited in
Lebow, 1962) asserted that the multidimensional nature of client expectancies meant
that the disconfirmation of any one expectation was not enough to have a detrimental
The Development of Research into Expectations About Counselling 5
treatment, it is not necessary to elaborate on this issue. However, it can be noted that satisfaction research shares many of the problems evident in other investigations into
expectations about counselling.
1
.
5
Expectations and
gender
Hardin and Yanico (1983) used the Expectations About Counseling questionnaire (EAC; Tinsley et al., 1980) to compare expectations, counsellor gender,
and problem type. This analogue study failed to find any significant effects attributable
to counsellor gender, but did show a significant main effect for subject gender. Also,
female subjects expected to assume more responsibility in counselling, and expected
counsellors to be more accepting, genuine, and confrontational than did the male subjects. In contrast, men expected counsellors to be more directive and self-disclosing than women did. The authors suggested that their design was not sufficiently sensitive
to extrapolate the complicated effect of counsellor gender.
An extension of Hardin and Yanico's (1983) work compared pre-counselling
expectations with subject gender traits (Sipps & Janeczek, 1986). Sipps and Janeczek postulated that previously observed differences in client expectations were not simply
due to gender but are instead attributable to the individual's level of femininity or masculinity. The results indicate that degree of femininity does significantly influence client expectations, irrespective of the client's gender.
1.6
EX.J}ectations
andservice utilisation
Kushner and Sher (1989) examined the relationship between fear of
psychological treatment and service utilisation. Treatment fearfulness was seen as " ... a subjective state of apprehension arising from aversive expectations surrounding the seeking and consuming of mental health services." (p.251). Based on scant prior research, the authors predicted that service seekers would be less fearlul than those who avoided treatment. Psychological distress and fear of psychotherapy were
measured with the Brief Symptom Inventory (BSI; Derogatis, 1975, cited in Kushner
& Sher, 1989) and the Thoughts About Psychotherapy Survey (TAPS; Kushner &
Sher, 1989) respectively. As predicted, treaanent avoiders displayed the highest level of fearfulness, followed by those who reported that they "never needed treatment". Those who needed treatment and sought it displayed the lowest level of fearfulness.
In conclusion, Kushner and Sher (1989) suggest that their results are consistent
with, but do not necessarily substantiate the view that fearfulness leads to service avoidance. The correlational design made it imprudent to infer any causal relationship
The Development of Research into Expectations AbouJ Counselling 6
who displayed more fear were more distressed prior to entering therapy. The authors
note that therapy can be " ... a potentially difficult, embarrassing, and overall risky
enterprise ... " (Kushner & Sher, p.256) and thus can be viewed in a negative or
fear-provoking way. This has practical implications in that many people who could benefit
from psychological help may avoid therapy because they find it frightening. This is
consistent with the views espoused in the current study. That is, the nature of an
individual's expectations (i.e. are they positive or negative) must be acknowledged if
service delivery is to be enhanced.
Tinsley et al. (1984) found that the client's view of the problem and the
perceived skills of the health professional involved can affect expectations and service
utilisation. They found that certain problems are seen as appropriate for some
help-providers but not for others and conclude that any study of help-seeking behaviour
needs to address the possible moderating influence of problem type. This means that
researchers need to rule out the possibility that treatment avoidance is simply due to the
client perceiving the identified help-giver as inappropriate for their specific problem
Paradoxically, Tinsley et al. (1984) cling to the view that failing to meet client
expectancies has negative consequences yet state that researchers must still answer the
question " ... just what are the effects of violating client expectancies?" (p.159). This is indicative of the degree to which the congruency hypothesis has become established in
this field despite the absence of strong empirical support. In response to Tinsley et
al.'s finding's, the current design controls for any unwanted variance attributable to
problem type.
1.7 Expectations and client ethnicity
Yeun and Tinsley (1981) used the EAC to compare the expectancies of American university students with those of African, Chinese, and Iranian students.
This study was born out of the increasing need to accommodate foreign students in
campus counselling settings and the acknowledgement of the possible role that ethnicity
plays in determining expectations. The authors point out that expectancies are modified
through interaction with the environment and therefore are strongly influenced by
cultural factors. Significant differences were found between the four groups of
students on 12 of the 17 expectancy scales. The authors observed that the Chinese,
Iranian, and African students expected to play a more passive role in the counselling
process. In contrast, the American students expected to assume more personal
responsibility while the counsellor adopted a less directive and passive role. Findings
like this reflect the degree to which extraneous factors such as socialisation and
ethnicity can impinge on the formation of expectations and therefore may cause
The Development of Research into Expectations About Counselling 7
made provision for subjects to indicate which ethnic group they identified with, thus
allowing for further analysis based on this information should the need arise.
1.8 General research into client expectations
Tinsley and Harris (1976) carried out an important study which looked at the
counselling expectations of 287 undergraduate students attending Southern Illinois
University. In contrast to other work at the time, they measured a wide range of client
expectations pertaining to the counsellor and the counselling environment. Close
examination of those expectations presented an insight into the way a
non-therapeutically sophisticated population views counselling. Essentially, the subjects
indicated that they believed counselling could be
generally
helpful but they doubted thatit could ever be of any help to them personally. In response, Tinsley and Harris
suggested that many potential clients may never seek counselling due to their low
expectancy that they will be helped.
This research was followed by the development of the Expectations About
Counseling questionnaire (EAC, Tinsley et al., 1980) which has become a popular
research instrument due to it's psychometric properties and ease of administration.
Tinsley et al. (1980) constructed this measure in order to address what they saw as the
inadequacies present in previous expectations research. They note, as did Duckro et al.
(1979), that previous efforts had focussed on too narrow a band of client expectancies
and had subsequently paid insufficient attention to prognostic and participant role
expectations. Hence, the EAC was constructed in order to try and measure " ... all of
the theoretically important expectancies a client might have about counseling." (Tinsley
et al., 1980, p.563). It includes scales which measure expectancies regarding:
counselling outcome, the client's attitudes and behaviours, the counsellor's attitudes
and behaviours, counsellor characteristics, and characteristics of the counselling
process.
Two advantages of the EAC over the customised instruments used in many
other studies are that it's widespread use allows for outcome comparisons between
studies and the standardisation of measurement procedures reduces unwanted variance
previously attributed to differing research methodologies.
Other research into. general expectations and attitudes about counselling has
been carried out using a variety of measures (Cash, Kehr, & Salzbach, 1978;
Surgenor, 1985; Furnam & Wardly, 1990). Cash et al. measured client help seeking
attitudes in an analogue study using the Fischer-Turner Attitudes Toward Seeking
Professional Psychological Help inventory (A TSPPH, Fischer & Turner, 1970, cited
in Cash et al., 1978). They found that therapeutically experienced subjects held more
The Development of Research into Expectations About Counselling 8
that the Fischer-Turner scale reliably differentiates between these. two groups. Those
who had not experienced therapy before expressed doubts about it's helpfulness. This
finding is consistent with the view that fostering positive or favourable attitudes
toward counselling will enhance service utilisation (Kushner & Sher, 1989; Tinsley &
Harris, 1976).
Surgenor (1985) used a modified version of the Fischer-Turner scale to
measure attitudes toward counselling in New Zealand. Young people and the
therapeutically naive displayed negative attitudes toward seeking and obtaining
psychological help while those who were therapeutically experienced, female, well
educated, and older displayed more positive attitudes. The author suggests that this is a
warning to psychology as a profession that there is a need to examine ways in which
services can be made available to all those who need it, not just a select few.
The idea that experience is an important determinant of attitudes toward
psychological help was also explored by Furnham and Ward.ley (1990). However, the pattern they observed was the opposite to that reported by Surgenor (1985). Overall,
the subjects' responses were mostly positive, but older subjects tended to be more skeptical about the benefits of psychotherapy while those who were more educated
believed less in it's possible benefits. However, the most important point was that
experience in psychotherapy correlated with higher levels pessimism about the
process. This finding is at odds with the research that has been cited up until now and
could be construed as support for the view that this area is poorly understood.
However, the most parsimonious explanation is that the use of a "psychotherapy"
rather than "counselling" client sample led to differing results.
One of the main benefits of general research into exr...,ctations about counselling
and psychotherapy is that it provides an insight into the clients perception of the encounter. The fact that practitioners are constantly exposed to their discipline
inevitably means that they lose touch with how a therapeutically naive person views the
experience. It is therefore desirable to gain an understanding of the expectations that
people bring with them to therapy in order to more effectively establish rapport and
trust. Hence, the current study is useful in that it quantifies the expectations of a group
of therapeutically naive clients, and by using the EAC it is possible to make
comparisons with other samples.
1.9 A
summary of the main problems with expectations research
In the most influential review of the expectations literature to date, Duckro,
Beal, & George (1979) challenge the assumption that the d.isconfinnation of client
expectations automatically has a deleterious effect on therapy process and outcome. Of
The Development of Research into Expectations About CoU11Selling 9
did not. This lack of concordance was attributed to the following methodological
limitations present in the literature.
Firstly, there has been a tendency for researchers to use ill-conceived research
methodologies (eg. Klepac & Page, cited in Duckro et al., 1979). This criticism
reflects Duckro et al.'s dissatisfaction with the means by which client expectations have
been measured by some researchers. For instance, some studies used open-ended
response forms which were subjectively interpreted by the investigator. In another
instance, the instrument items were objectively generated but were administered
verbally by an intake worker giving rise to the suggestion that a positive response bias occurred. These concerns are also voiced by Tinsley, Bowman, & Ray (1988) who
advocate a programmatic approach to expectations research. They recommend the use
of the EAC due to it's psychometric properties, widespread use, and broad focus.
A second weakness of previous research relates to ambiguity regarding the
definition of "expectations". Apfelbaum (1958, cited in Duckro et al., 1979) defined
expectations as the anticipation of some event. However, this practice of stating clear
construct definitions has not been emulated by many other authors and consequently, the problem of separating client expectations from client preferences has emerged. To
avoid these problems, Duckro et al state that researchers should clearly define client "expectations" at the outset of any study. In response to this, the current study adopts a precise operational definition of "expectations" taken from the work of Grantham and Gordon (1986). (See Section 4.2).
A final concern expressed by Duckro et al. (1979) is that the theories that have been used in this area in the past have predominantly been inappropriate and have not
enhanced the development of the field. The current study acknowledges all of these
concerns in it's design: A psychometrically sound and widely used research instrument has been chosen - the EAC. A clear definition of "expectations" has been selected, and
an attempt is being made to forge a link between appropriate theory and applied
CHAPTER TWO
Preparation for Stressful Medical Procedures and Self Regulation Theory
2.1 Rationale for drawin~ on the medical psycholo~y literature
10
As has already been noted, one of the main criticisms of research into
expectations about counselling is that many authors have uncritically accepted spurious
theoretical assumptions (such as the congruency hypothesis) and have ascribed them
factual status. Recognition of this failing has prompted a call for the reappraisal of the
models and theoretical constructs used in expectations research (Duckro et al., 1979).
One way of enhancing this process is by taking note of the theoretical developments
that have occurred in related areas, such as medical psychology, and introducing them
into investigations of expectations about counselling. For instance, the effects of
preparation for stressful medical procedures has received considerable attention in
recent times and, unlike research into expectations about counselling, the development
of theory has kept abreast of applied res~arch.
There are two main reasons for turning to the medical psychology literarure for
theoretical input. Firstly, surgery and psychological counselling share a number of
characteristics. For instance, they both represent relatively ambiguous situations to the
uninitiated and inexperienced; they are both invasive (one at a physical level, the other at an emotional level); and they both involve what Kushner & Sher (1989) termed the
" .. .letting go of the familiar and a taking on of the unknown." (p. 256). Secondly,
given that the current research focusses on anxiety about counselling, the fact that the single most commonly reported preoperative emotional state is anxiety (Johnston,
1986) makes it sensible to capitalise on the advances made in the medical psychology literature.
2.2 An overview of research into copin~ with stressful medical procedures
A number of techniques have been used to enhance patient coping with stressful
medical procedures including: psychological support; information provision; skills
training; hypnosis; relaxation training; filmed modeling; and cognitive-behavioural
interventions (Kendall & Watson, 1981). Of these strategies, the effects of information
provision prior to the stressful event has received most of the research attention and the
most promising results (Johnson, 1973; Ridgeway & Mathews, 1982; Anderson,
1987; Johnson, Lauver, & Nail, 1989; Suls & Wan, 1989).
One of the main findings to emerge from this literature that is relevant to the
current study regards the importance of fostering accurate, but non-threatening
Preparation for Stressful Medical Procedures - Self-Regulation Theory 11
out a series of experiments which looked at the effects of preparatory information on
subject expectations and subsequent distress associated with artificially induced
ischernic pain. The experimental group were given information regarding the types of
sensations that most people experience when they have a tourniquet applied to their
upper arm. The control group were only provided with information about the
procedure of the study. The main hypothesis was that accurate expectations about the
physical sensations that were to be experienced would reduce the distress displayed by
the subjects. However, Johnson found that a reduction in distress only occurred when
the individual held accurate expectations about the sensations to be experienced and
directly experienced those sensations. Prior to actually experiencing the ischernic pain,
there was no difference in anticipated levels of distress for the experimental and control
groups. It was suggested that information provision helped subjects structure their
expectations and quell any fears arising from not being able to anticipate what was
going to happen. Hence, when the sensations occurred, they could be processed in
non-threatening terms because they were congruent with what was expected. In
contrast, those who did not receive preparatory information lacked an appropriate
reference point and thus were unable to ascertain whether the sensations were going to
intensify, diminish or remain constant. It is likely that this ambiguity lead to
anticipatory arousal and distress due to a lack of understanding of what could occur next. Thus, facilitating the formation of accurate expectations appeared to provide a
cognitive template against which subjects could compare their experience. The likely
effect of this was the reduction of the arousal that can occur when the future is
unknown and potentially unpleasant.
2.3 Sensory Vs,
orocedural preoaratory information
As research into pre-operative preparation has expanded it has become clear that
preparatory techniques can differ markedly in terms of both their emphasis and
subsequent effects. For instance, a clear distinction can be made between sensory
information which describes the sensations that the patient is likely to experience, and
procedural information which only describes the sequence of events that the individual
will be exposed to (Suls & Wan, 1989). The emergence of this distinction has
prompted the examination of how different types of preparatory information affect
coping and surgical outcome.
Ridgeway & Mathews (1982) provided hysterectomy patients with one of three
types of pre-operative information. The two experimental groups were given either:
(a) information about the surgical procedure and it's effects; or (b) guidance in a
cognitive coping technique. The control group was given general information about the
Preparation/or Stressful Medical Procedures - Self-Regulation Theory 12
experimental groups experienced reductions in anxiety about the operation compared to
controls, but training in the cognitive coping technique was associated with the best
outcome. Ridgeway and Mathews suggest that the cognitive coping condition was
most effective because it invested the patient with a transferable skill which could be
applied to any concern or worry that they experienced. The other advantage of the
cognitive coping strategy was that it could continue to be beneficial during the
post-operative recovery period. In contrast, the provision of information on it's own could
only address a limited number of specific issues and therefore could miss some of the
idiosyncratic concerns that an individual may have.
These findings indicate that expectations can not be treated as a unitary
construct Therefore, adopting the perspective of many researchers in the expectations
about counselling area and concentrating on improving only the accuracy of an
individuals expectations fails to acknowledge other subtle effects that can determine
coping and outcome. The relevance of this to the current study lies with the
supposition that the content (specifically, the affective valence) of an individuals
expectations affects coping with a stressful c;vent. As has already been noted, it is
nonsensical to confirm a client's negative expectations without giving them appropriate
coping skills or the understanding that the aversive qualities of the experience are
transient and are a natural part of the therapeutic process.
Stress inoculation procedures have also been used to help surgical patients form
active coping behaviours to mitigate the distress associated with hospitalisation and
surgery (Wells, Howard, Nowlin, & Vargas, 1986). The experimental group in Wells
et al.'s study experienced less pain and anxiety than controls, were less reliant on
analgesic medication post-operatively, and were discharged from hospital an average of
3.5 days earlier. Also, in keeping with the idea that holding positive views is an
important determinant of a good therapeµtic outcome, Wells et al. note that positive
patient perceptions of their primary surgeon correlated with less reported worry and
nervousness about the surgery.
The main conclusion that emerges from the medical studies cited above echoes
much of what is stated in the theoretical literature (Johnston, 1986). That is,
predictability and perceived control over an event are important determinants of the
degree to which an individual can cope. Although providing accurate information does
lead to reductions in distress, it is not the most efficacious way of helping the individual
to cope with anxiety-provoking situations. In response to these observations an
number of authors have attempted to model the relationship between pre- and
Preparation for Stressful Medical Procedures - Self-Regulation Theory 13
2.4 Expectations, pre-operatire emotional states and recovery
Johnston ( 1986) completed a comprehensive critique of the theoretical models
developed to explain the relationship between pre-operative emotional states and
post-operative recovery. In addition to this, the review identified fallacious theoretical
assumptions from those which were based on empirically sound studies. The
subsequent findings that are relevant to the present study are as follows:
(a) patients who displayed high pre-operative anxiety experienced poor
post-operative outcomes. In contrast, those who displayed low
pre-operative anxiety experienced good outcomes.
(b) those patients who displayed an active and energetic (positive)
pre-operative mood were most likely to demonstrate fast post-pre-operative
recovery.
(c) inaccurate patient expectations prior to surgery only correlated with
post-operative difficulties if the problems were underestimated. This
point was made with particular reference to expectations about post~
operative pain, that is, those who underestimated the amount of pain experienced more post-operative difficulties. This is in contrast to other
research that suggests any inaccurate expectation will result in a poor
post-operative outcome (Johnson, 1973, Leventhal & Johnson, 1983).
The relevance_of these findings to research into expectations about counselling
is twofold: Firstly, the presence of a reliable correlation between low pre-operative
anxiety and good post-operative outcome lends strong support to the view that reducing patient anxiety prior to psychotherapy is desirable. Intuitive thinking along these lines
has prompted a lot of the work aimed at preparing people for both psychotherapy and
stressful medical procedures (see Tinsley et al, 1988; and Ridgeway & Mathews, 1~82,
for reviews). Secondly, as in the expectations about counselling literature, the exact
influence of accurate patient expectations is ambiguous (see point (c) above).
However, instead of persevering with obsolete theory as has been done in the
counselling literature, the field of medical psychology has built on the findings of
previous research and has developed models that equate with what has been observed
in empirical studies.
2.5 The development of theory
Johnston (1986) presents an analysis of nine theoretical positions that have been
developed to explain the ways pre-operative emotions influence recovery. These
perspectives range from strict psycho-physiological explanations which implicate the
body's biochemical response to perceived stress, to the other extreme which postulates
Preparation for Stressful Medical Procedures - Self-Regulation Theory 14
influences the assessments made by medical staff). In between these two extremes is
the school of thought which assimilates a cognitive-behavioural perspective with
physiological variables.
One of the earliest theories to account for the influence of preoperative
emotional states on recovery was by Janis (1958). This Emotional-Drive model was
predicated on the idea that a certain amount of anxiety was needed to motivate an
individual to engage in active coping behaviours. Janis posited a curvilinear
relationship between preoperative anxiety and outcome, and suggested that patients
needed to engage in the "work of worry" if they were to cope adequately with the
stressful event. However, subsequent research has failed to replicate Janis' original
findings (Johnston, 1986; Johnson, Lauver, & Nail, 1989) and thus it is no longer
viewed as a tenable theory.
The models that have proven to be more heuristic than Janis' Emotional-Drive
Theory suggest a linear relationship between pre- and post-operative emotional states.
Leventhal (1970, cited in Leventhal & Johnson, 1983) proposed that there are two
distinct responses to a threatening situation: (a) attempt to deal with the fearful
response, and (b) attempt to deal with or avert the impending threat The experience of
fear does not automatically prompt the individual to engage in danger control
behaviour, instead, this response is influenced by factors such as locus of control and
perceived controlability of the threatening situation. Therefore, if an individual does
not possess the requisite skills to engage in danger control, or if they believe that the
situation is out of their hands they will attempt to mitigate the fear reaction instead. So,
rather than attempting to cope with the stimulus that is eliciting the fearful response,
they will attempt to cope with the response itself. This view is incompatible with
Emotional-Drive theory as it infers that increasing an individuals level of anxiety will
not automatically elicit the emission of an appropriate coping response if one is not
available. Instead, what is likely to happen is that an increase in anxiety will elicit a
reaction designed to cope with the anxiety, not the situation causing it.
These ideas were further developed by Johnson (1973) who examined whether
making the sensations associated with surgery more predictable enhanced the emission
of a coping response. The results of this and numerous other studies have been used as
the empirical base from which self-regulation theory has developed (Leventhal &
Johnson, 1983).
2.6 Self-reeulation theory
Self-regulation theory is an information processing model which has been
systematically developed from a broad experimental and applied research base. It has
Preparation for Stressful Medical Procedures - Self-Regulation Theory 15
individuals cope with stressful events such as: gastroendoscopy (Johnson, Morrissey,
& Leventhal, 1973, cited in Leventhal & Johnson, 1983); radiation therapy (Johnson et al, 1989); and childbirth (Leventhal, Leventhal, Shacham, & Easterling, 1989).
Leventhal and Johnson contend that the provision of accurate, non-emotional,
pre-operative information allows the formation of an appropriate cognitive representation
(schema) of the impending event. The presence of this schema then facilitates the
non-threatening interpretation of environmental events which results in reduced patient
distress and enhanced post-operative recovery.
One of the strengths of this model is that it has developed in a number of
inductive (theory-generating) and deductive (theory-testing) steps which have allowed
the systematic rejection of any spurious assumptions (Wooldridge & Schmitt, 1983).
Also, the studies on which the theory is based display a range of methodologies and
were carried out in a number of different settings.
To provide an indepth critique of the research from which the theory has
emerged here would be redundant given that: (a) it is accepted that the broad range of
research techniques used in the development of the model make it difficult to question
it's validity based on any major methodological concern (Wooldridge & Schmitt,
1983), and; (b) detailed reviews are available elsewhere (eg. Leventhal & Johnson,
1983; Johnson, 1982). Therefore, the following discussion does not seek to critically
appraise the research base of the self-regulatory model, instead it highlights it's
relevance to the current study.
2.7 Two
interpretations of the self-refulation model
The fact that self-regulation theory has developed from both experimental and
applied research has lead to the emergence of two distinct, but closely related
interpretations of the model. Both perspectives attempt to encapsulate the cognitive
process that accompany the provision of sensory pre-surgical information. The
interpretation favoured by Howard Leventhal is derived primarily from the findings of
laboratory based experimental studies in which the subjects' opportunities to engage in
active coping behaviours are scarce. This perspective focuses on the role that sensory
information plays in the reduction of the patient's distress reaction. In contrast, the
view favoured by Jean Johnson is based on the findings of field research in which the
individual may emit a range of active coping behaviours. Thus, Johnson emphasises
the role that sensory information plays in facilitating coping. Both auLhors agree that
the provision of accurate sensory information prior to a stressful medical procedure is
beneficial because it provides the individual with an accurate schema of the impending
Preparalionfor Stressful Medical Procedures· Self-Regulation Theory 16
2.8 Leventhal's interpretation
It is proposed that there are two possible responses to the presence of a n·oxious
environmental event: (1) a basic informational response which maps the event's
parameters at a neurological level in terms of its intensity, temporal magnitude, and
sensory properties such as appearance and feel; and (2) an emotional-distress response
characterised by a specific pattern of autonomic arousal (Leventhal & Johnson, 1983).
Leventhal holds the view that sensory information acts to reduce the intensity of the
emotional-distress response by preventing the association of the current experience with
emotionally laden memories. It is suggested that noxious stimuli prompt severe
emotional reactions when they are linked in memory with prior events where the
individual experienced emotions such as anxiety, distress, anger, and so forth.
It is suggested that the linking of current experience with emotional memories
occurs automatically at a preconscious level and as such is beyond the voluntary control
of the individual. In order to gain some clarification of this issue, Leventhal, Brown, Shacham, and Engquist (1979) conducted an elaborate experimental study which
looked at the influence of different types of preparatory information on reports of pain
and distress during exposure to a cold pressor stimulus. Three pairs of groups received
the following types of preparatory information: (a) that which described the sensations
produced by the cold-pressor stimulus (such as coldness, numbness, tightness of the
skin); (b) procedural information about the sequence of events that would occur, and;
(c) information regarding the common bodily symptoms that accompany arousal due to
fear or distress (butterflies in the stomach, sweating on the non-immersed hand and so
on). In addition to this, one pair from each information condition were given the
following pain cue as part of the general instructions: 11
• • • you will notice the ... sensation of pain, which will begin to get very strong about this time. 11
(Leventhal et
al., p.693). The inclusion of this additional information was intended to alter the
connotations of the situation so that for three of the groups the emergence of each
sensation could be construed as a signal of imminent severe pain.
This design allowed the exploration of two possible influences of sensory
information. Firstly, if the accuracy of the information is most important the
inclusion of the pain cue should not affect the observed level of distress as it merely
represents another piece of accurate information. The alternative perspective suggests
that the automatic, preconscious interpretation of the sensations is what matters.
Therefore the presence of the pain cue will connect the stimulus to emotional memories
thereby suppressing the distress reduction usually seen with sensory information.
The results indicate that the provision of accurate sensory information without
the pain cue was most effective at reducing subject distress. This lead the authors to
Preparation for Stressful Medical Procedures - Self-Regulation Theory 17
interpret environmental events in non-threatening terms. Leventhal et al. (1979)
completed two more experiments which were designed to indicate whether sensory
information led the subject to form a concrete schema that prevented the stimulus from
eliciting noxious emotional memories. It was concluded that the effect of sensory
information is twofold: (a) it reduces the anticipatory arousal induced by surprise,
uncertainty and perceived threat, and (b) it reduces distress by facilitating rapid
habituation to the fear response, that is, it prevents the connection of the current experience with previous noxious emotional experiences.
This habituation hypothesis is the main factor which distinguishes between Leventhal and Johnson's respective interpretations of the self-regulation model. It
predicts that providing sensory information will facilitate habituation and reduce
distress by allowing for the more rapid formation of a schema of the event, thereby
reducing it's novelty and/or activating power (Leventhal et al., 1989). However, this
pattern has only been observed in experimental studies in which the participant could
engage in few active coping behaviours. Research in applied settings, such as that
carried out by Johnson and colleagues (Johnson, 1973; Johnson & Leventhal, 1974;
Johnson & Rice, 197 4) supports the view that, rather than directly affecting the individual's emotional response, sensory information exerts an indirect influence through it's effects on coping (Leventhal & Johnson, 1983).
2.9 Johnson's interpretation
The findings of research in clinical settings suggest that sensory preparation is
beneficial because it increases the individual's ability to process information and
subsequently apply appropriate coping strategies from their existing repertoire
(Leventhal & Johnson, 1983). Unlike subjects in Leventhal's laboratory studies,
participants in clinical field studies are placed in situations in which they can take overt
action to reduce their distress. Several studies have shown that providing guidance in
active coping behaviours and instructing subjects to monitor specific sensations
associated with the impending event results in reductions in both self reports and
behavioural indices of distress (eg. Johnson & Leventhal, 1974; Leventhal et al.,
1989).
The cognitive intervention used in the clinical studies carried out by Johnson
served the following functions: It described the impending sensations in objective
terms; identified the cause of those sensations; and gave an indication when each
sensation would be likely to terminate. This provision of accurate, objective
information served the dual purpose of indicating to the subject what was going to
happen, while also quelling any distress related to worry over what could possibly
Preparation/or Stressful Medical Procedures - Self-Regulation Theory 18
experience could be compared. This permits the evaluation of any emitted coping
response and the modification of that response in a proactive rather than reactive
manner.
Johnson (in Leventhal & Johnson, 1983) likens the schema to a road map in
that it allows one to proceed toward a specified goal without having to focus on every
detail along the way. As a person experiences feedback that is consistent with the
schema, confidence in the schema's predictive ability will increase and the individual
will become more confident in their ability to cope. In contrast, the absence of an
appropriate cognitive map will promote anticipatory arousal and distress because there
is no indication when the experience will end or how the individual has fared. This will
give rise to a perceived lack of control and will hamper the emission of coping
behaviours.
Langer, Blank, & Chanowitz (1978) suggest that the main benefit of an accurate
schema is that it allows the guidance of behaviour by specific situational cues without
the individual having to concentrate on those cues. Hence the depletion of information
processing resources is avoided and the individual is able to concentrate more fully on
the task in hand Because the schema operates at a relatively automatic level and makes
use of the individual's existing repertoire of coping behaviours there is no need to
struggle with the acquisition of new skills - the provision of preparatory information
has obviated this need.
2.10
Summary
The different perspectives on self-regulation theory presented by Leventhal and
Johnson appear to be a function of the differing research settings in which they were
conducted. The experimental setting served to emphasise the habituation process as it
virtually precluded the emission of active coping behaviours, whereas the applied
setting allowed the individual to assume a more active role. However, both authors
agree that successful adaptation to stressful circumstances requires the formation of a clear representation of the environment (the schema) and guidance in appropriate coping
behaviours. The individual must also be able to gain a clear indication of what
constitutes successful coping so that the coping behaviours that are being emitted can be evaluated and modified as necessary. Finally, the experience must be seen as
non-threatening, that is, the individual must interpret subsequent sensations in benign terms
and be confident in their ability to cope.
The model proposed by Leventhal and Johnson (1983) relates to the current
study in the following ways. Firstly, it refutes the view that mere accuracy of
information is enough to facilitate coping. This is exemplified in the work of Leventhal
Preparation for Stressful Medical Procedwes - Self-Regula.lion Theory 19
by including a simple pain cue increased distress. The accuracy of the preparation
remained unchanged but the connotations of the sensations were altered such that they
changed from being objective stimuli to signals of impending pain. This reframing of
the sensations in threatening terms enhances the likelihcxxi that the individual will try to form a schema based on previous pain experiences and this will result in the recall of
the noxious emotions that were associated with those experiences. Thus, the
self-regulation model adds theoretical support to the view espoused in the current study, that
is, that the emotional valence of an individuals expectations (their schema if the
impending event) will have a dramatic effect on the amount of distress they experience.
The next chapter examines more closely the role that the valence of an
individual's expectations will play in determining _emotional arousal by combining
Leventhal and Johnson's self-regulation theory with the attentional-bias model
CHAPTER THREE
The Attentional-Bias Model
3.1 Perceived threat and emotional arousal
20
Many researchers have found that providing information prior to a potentially
noxious event reduces distress and enhances coping both during and after the event
(Johnson, 1973; Johnson & Leventhal, 1974; Langer, Janis, & Wolfer, 1975; Kendal.I,
Williams, Pechacek, Graham, Shisslak, & Herzoff, 1979; Ridgeway & Mathews,
1982; Suls & Wan, 1989). The self-regulation model proposed by Leventhal and
Johnson (1983) suggests that it is beneficial to provide concrete, objective preparatory
information which frames an impending experience in non-threatening terms. This
allows the individual to form an accurate schema of an event and minimises anticipatory
arousal. This model shows potential for expanding our understanding of the way first time counselling clients cope with the stress of the initial session. However, before
exploring this idea it is necessary to address an under-developed aspect of the
self-regulation model.
Although Leventhal (in Leventhal & Johnson, 1983) alludes to some
preconscious process which leads to schema formation and subsequent levels of
distress , the self-regulation model fails to adequately specify the nature of this process.
Therefore, there is a need to draw input from other work.
3.2 The attentional-bias model
Mathews & MacLeod (1985) posit an information processing model which
provides insight into way that focussing on threatening environmental cues can give
rise to the cognitive and physiological correlates of anxiety. Their contention is that
anxiety states are attributable to the selective processing and interpretation of threat
cues. They have observed that some individuals preferentially direct attentional
resources toward threatening environmental cues and experience an increase in anxiety,
while others direct their attention away and display less anxiety.
Almost all of the research in this area has been aimed at substantiating the view
that generalized anxiety disorder is attributable to the presence of stable personality factors (trait variables), specifically, a predisposition to attend to threatening
environmental cues. However, this does not limit the value of the model in the context
of the current research. Rather the findings augment the view that the degree to which
an individual sees an impending event in positive or negative terms will affect the
level of anxiety displayed by that individual. Also, the tenninology and constructs used
by researchers exploring attentional-bias effects are closely related to those used by
